Qualifying Change Form

Flexible Spending Account

Qualifying Change Form

Name (Last, First, MI): / Social Security Number: / Daytime Phone:
Street Address: / City: / State: / ZIP Code:
Date of Qualifying Event: / Last Pay Date (Office use only) / Benefit Effective Date / Agency/Division Code
______/______
Type of Qualifying Event—Please select appropriate event(s)
Marriage
Divorce
Annulment
Began Family Medical Leave Act (FMLA) period (Start Date______)
Ended Family Medical Leave Act (FMLA) period (End Date)
Became eligible for Medicare or Medicaid coverage / Lost eligibility for Medicare or Medicaid coverage
Judgment, decree or court order
Death of spouse or dependent
Dependent is no longer a qualified tax dependent
Explain:
Change in employee’s or dependent’s employment status
Did spouse’s employment status change? Yes No
Birth, adoption or placement of adoption of a child / For DCAP only:
Child turned age 13
Change in the cost
of care
Changes to Health Care Spending Account (HCSA) Contributions / Office Use
# of Checks Remaining
of __
Per Check Amount
I wish to change my Health Care Flexible Spending Account contributions. My annual contribution amount will change from $ to $______(not to exceed $2,550).My per-paycheck deductions will change accordingly, starting with the second paycheck of the month after the latter of (1) the date of the qualifying event or (2) the date this form is received by ASIFlex.
I wish to cancel my Health Care Spending Account contributions.
Changes to Health Care Spending Account (for FMLA only)
When beginning FMLA:
I wish to continue my Health Care Spending Account participation while on FMLA. I must send after-tax payments to ASIFlex.
I wish to discontinue my Health CareSpending Account participation while on FMLA. I cannot request reimbursement from my Flexible Spending Account for expenses incurred while on FMLA.
When ending FMLA and returning to work:
I wish to reinstate my Health Care Spending Account at the same annual amount. My per-paycheck deduction will increase accordingly.
I wish to reinstate my Health Care Spending Account at the same per-paycheck amount. This will reduce the annual amount I originally elected.
Changes to my Dependent Care Flexible Spending Account (DCAP) / Office Use
# of Checks Remaining
of ____
Per Check Amount
I wish to change my Dependent Care Assistance Program contributions. My annual contribution amount will change from $ to $ (not to exceed $5,000). My per-paycheck deductions will change accordingly, starting with the second paycheck of the month after the latter of (1) the date of the qualifying event or (2) the date this form is received by ASIFlex.
I wish to cancel my Dependent Care Assistance Program contributions.

I understand:

• I or an eligible dependent has had a qualifying change in status, as defined by the Internal Revenue Service, which allows me to change my previous Health Care Spending Account and/or Dependent Care Assistance Program election.
• This form cancels any prior elections I have made under this plan, and cannot be changed except as stated in the Participant Handbook.

Employee SignatureDate

Payroll Coordinator SignatureDate

Please return this form to your Human Resources.